This chapter gives the findings from the analysis relating to the second research question, which was ‘How do staff experience and intermediate outcomes link with organisational performance (e.g. patient satisfaction, mortality, infection rates), and is there a mediated link from experiences to performance via
intermediate outcomes?’. This again included three main types of analysis: latent growth curve modelling,
cross-lagged correlation tests and mediated regression. As in Chapter 6, these three are reported separately but findings are brought together.
The main findings from this research question are that the relationships with organisational performance are complex. There is clear evidence of significant (and often strong) links between staff experience and patient satisfaction, although this does not appear to be mediated by intermediate outcomes. The longitudinal effects are much less clear. There were some links between changes in staff experiences and subsequent improvements in patient outcomes, but this was not consistently found across all predictors and all outcomes. The cross-lagged correlations failed to reveal a consistent pattern of results to provide evidence for causal relationships.
In terms of the mediation, a striking finding was that although many staff experiences were associated with absenteeism and with patient satisfaction, there were not any mediated effects here. That is, the reason for staff experiences affecting absenteeism appears completely separate from the reason they affect patient satisfaction. Given that both are important for trusts for different reasons, this points to an even greater importance of staff attitudes and experience.
Chapter structure
The analysis conducted for this chapter was extensive and, thus, the full results of each analysis are not reproduced in the main body of the report. The full tables of results can be found in Appendices 5 and 6. Summary tables, with enough information to show the findings of primary interest, are instead given in the main body of the report. Within this chapter, the latent growth curve analysis is presented, with staff experiences and intermediate outcomes predicting trust outcomes (patient satisfaction, mortality, and two forms of infection rates), and the equivalent cross-lagged correlation analysis is also presented, as are results of mediated regression analysis. Summary of results identifies common themes between the different types of analysis and what can be concluded with appropriate levels of confidence from the findings. Because of the nature of these trust outcomes, they apply only to acute trusts. Therefore, the analysis in this chapter is for acute trusts only.
Latent growth curve analysis
There were two stages of latent growth curve analysis completed and each is used for a slightly different interpretation. Both stages predicted levels, and changes, in intermediate outcomes from 2009/10 to 2011/12; the first stage used 2009 staff experience variables as predictors, whereas the second stage used
differences from 2009 to 2010 (denoted with a‘D’ suffix in Appendix 5, Tables 41–48), to examine whether or not there was any evidence of change in staff experience affecting longer-term change in intermediate outcomes.
Owing to the complexity of the latent growth curve analysis procedure, there were occasionally statistical problems preventing the estimates being achieved, which is a common problem with latent variable procedures. In order to circumvent this, in some cases we had to omit control variables from the models to get estimates. These cases are clearly indicated in the relevant tables.
Table 12 shows the significant relationships between staff survey variables from 2009, intermediate outcomes from the same year, and the starting level (intercept) in patient satisfaction, mortality, and infection rates for both MRSA and C. difficile. These indicate where there are significant cross-sectional relationships between aggregate staff experience and outcomes.
In summary, we can see that for patient satisfaction, there were many significant relationships and satisfaction was higher when:
l fewer staff work extra hours
l more staff have received any training and development and, in particular, health and safety training
l more staff feel valued by their colleagues
l staff report lower work pressure
l a higher percentage of staff have appraisals and personal development plans
l fewer staff report experiencing violence, harassment, bulling and abuse from patients and their
relatives; it is also higher where staff perceive that action taken from the employer towards violence and harassment is effective
l the perceived fairness and effectiveness of incidence reporting is high
l more staff feel that they are able to contribute towards improvements at work
l there are high levels of job satisfaction among staff and lower intentions to leave jobs
l staff report that they would be more likely to recommend their trust as a place to work or
receive treatment
l where staff believe that the trust provides equal opportunities for career progression or promotion
and where fewer staff report experiencing discrimination at work
l there is a higher availability of hand-washing materials
l staff report high levels of engagement
l there are lower objective turnover rates (i.e. higher stability)
l there were fewer significant associations with patient mortality, but still some important
(and theoretically expected) significant findings. In particular, mortality was lower when:
¢ more staff report that they understand their role and where it fits in
¢ more staff feel able to contribute towards improvements at work
¢ staff are more likely to recommend the trust as a place to work or receive treatment
¢ staff report higher overall work engagement.
However, mortality was also lower when more staff experienced physical violence from patients or their relatives. This is unexpected and also appears to be an anomaly because when compared with other types of analysis and different years, this was not replicated. Therefore, it is most likely to be a type I error. For infection rates, one finding was that higher levels of harassment, bullying and abuse from patients or their relatives was associated with higher MRSA rates. If there is a genuine link between these two variables, then causality in either direction (or both) is perhaps reasonable. However, this is somewhat contradicted by the finding that such higher rates (as well as higher rates of work pressure and of shift working) are associated with lower C. difficile rates. This suggests that links with infection rates in general may not be very understandable.
TABLE 12 The NHS staff survey key findings 2009 as predictors of starting levels (intercepts) of trust outcomes
Outcome Predictor Coefficient p-value
Controls not included
Patient satisfaction % receiving any training or development in previous 12 months
35.508 0.002
% feeling valued by colleagues 25.257 0.001 Work pressure felt by staff –4.969 0.036 % appraised within previous 12 months 5.773 0.013 % with personal development plans agreed within previous
12 months
7.322 0.003
% having had health and safety training in previous 12 months
7.701 0.006
Fairness and effectiveness of incident reporting 11.227 0.001 % experiencing physical violence from patients or their
relatives in previous 12 months
24.831 0.013
% experiencing harassment, bullying or abuse from other staff in previous 12 months
–21.785 0.009
Perceptions of effective action from employer towards violence and harassment
7.227 0.012
% able to contribute towards improvements at work 7.656 0.030 Job satisfaction 8.807 0.009 Intention to leave job –7.393 0.000 Staff recommendation of the trust as a place to work or
receive treatment
7.628 0.000
% believing trust provides equal opportunities for career progression or promotion
26.748 0.000
% experiencing discrimination at work in last 12 months –43.299 0.000 Availability of hand-washing materials 13.343 0.000 Overall engagement 10.198 0.000 Stability index 0.289 0.003 Patient mortality % experiencing physical violence from patients or their
relatives in previous 12 months –63.352
0.031 Trust type
% agreeing they understand their role and where it fits in –19.301 0.037 Trust type % able to contribute towards improvements at work –46.39 0.008 Trust type Staff recommendation of the trust as a place to work or
receive treatment
–9.835 0.016 Trust type
Overall engagement –17.324 0.026 Trust type MRSA rates % experiencing harassment, bullying or abuse from
patients or their relatives in previous 12 months
8.688 0.034
C. difficile rates % staff working shifts –67.353 0.004 Work pressure felt by staff –26.701 0.029 % experiencing harassment, bullying or abuse from
patients or their relatives in previous 12 months –150.60
Table 13 shows the significant relationships between staff survey variables from 2009 and the change (slope) in trust outcomes. These indicate where starting levels of staff experience are associated with subsequent changes in outcomes. These are more difficult to interpret because a drop in patient mortality
(for example) may be due to a very high starting level– in other words, regression to the mean. Therefore,
we recommend not interpreting these results particularly strongly, but instead focusing on the (far stronger) results in later tables. However, they are included for the sake of completeness. Indeed, some results (notably the positive links between work pressure and percentage staff experiencing harassment, bullying and abuse from patients or their relatives and changes in C. difficile rates) may partially explain the contradictory results in the previous table; when such negative experiences are high, there may also be a low starting value of infection rates, but these rates then increase over time.
A much stronger form of the analysis is using changes in staff experience (i.e. differences in staff survey variables between 2009 and 2010) as predictors of the change in intermediate outcomes (slopes). Table 14 shows the significant results from this analysis. In summary:
l An increase in the reported negative impact of health and well-being on employees’ ability to perform
their work and daily activities is associated with a decrease in patient satisfaction.
TABLE 13 The NHS staff survey key findings 2009 as predictors of changes (slopes) in intermediate outcomes
Outcome Predictor Coefficient p-value
Controls not included
Patient mortality % feeling valued by colleagues 25.768 0.013 Trust type % suffering work related injuries or illness –26.105 0.044 Trust type % experiencing physical violence from patients or their
relatives in previous 12 months
27.909 0.046 Trust type
MRSA rates % having had health and safety training in previous 12 months
1.674 0.049
% experiencing harassment, bullying or abuse from
patients or their relatives in previous 12 months –7.39
0.002
C. difficile rates Work pressure felt by staff 12.193 0.031 % experiencing harassment, bullying or abuse from
patients or their relatives in previous 12 months
58.848 0.002
TABLE 14 The NHS staff survey key findings (changes from 2009 to 2010) as predictors of changes (slopes) in intermediate outcomes
Outcome Predictor Coefficient p-value
Controls not included
Patient satisfaction Impact of health and well-being on ability to perform work or daily activities
3.778 0.041
Patient mortality Perceptions of effective action from employer towards violence and harassment
–10.321 0.044
% staff working shifts 49.344 0.039 Foundation status MRSA rates Line manager support –2.254 0.008
C. difficile rates % staff working shifts –89.545 0.018 Foundation status % feeling there are good opportunities to develop
potential at work
–26.423 0.036
Fairness and effectiveness of incident reporting –23.556 0.049 % experiencing harassment, bullying or abuse from
patients or their relatives in previous 12 months
l An increase in shift working is associated with an increase in patient mortality rates.
l An increase in perceptions of effective action from employer towards violence and harassment is
associated with a decrease in patient mortality rates.
l An increase in line manager support is associated with a subsequent drop in MRSA rates.
l An increase in staff feeling there are good opportunities to develop potential at work and an increase
in the fairness and effectiveness of incident reporting procedures are associated with a subsequent drop in C. difficile rates.
l However, an increase in shift working and in experiencing of harassment, bullying or abuse from
patients or their relatives, is also associated with a drop in C. difficile rates.
Cross-lagged correlations
Cross-lagged correlations compare the relationship between two variables in subsequent years, testing whether or not there is a stronger effect in one direction than the other. Full results are in Appendix 2, but Table 15 shows the significantly different cross-lagged correlations between staff experience and
TABLE 15 Cross-lagged correlations between staff survey variables and intermediate outcomes. The p-value represents test of the null hypothesis that the correlations are equal
Staff survey variable or intermediate outcome Trust outcome
Staff variable year 1 and outcome year 2 Outcome year 1 and staff variable year 2 p-value Absenteeism 2010–11 Mortality 11–12 0.45 0.32 0.04 Absenteeism 2010–11 C. difficile 10–11 0.03 0.19 0.03 Stability 2007–8 Mortality 07–08 0.27 –0.15 0.00 Stability 2009–10 Mortality 09–10 0.46 0.19 0.00 Opportunities for flexible working Mortality 10–11 0.24 –0.02 0.00 % experiencing discrimination at work Patient satisfaction 10 –0.45 –0.64 0.01 % believing that trust provides equal opportunities
for career progression or promotion
Patient satisfaction 10 0.43 0.57 0.05
Opportunities for flexible working Patient satisfaction 10 0.07 0.28 0.01 Quality of job design (clear job content, feedback
and staff involvement)
Patient satisfaction 10 0.10 0.28 0.02
% experiencing harassment, bullying or abuse from patients or their relatives in previous 12 months
MRSA 10–11 –0.14 0.12 0.01
Staff recommendation of the trust as a place to work or receive treatment
MRSA 10–11 0.19 0.01 0.04
% reporting good communication between management and staff
C. difficile 10–11 –0.21 0.02 0.00
% agreeing their role makes a difference to patients
C. difficile 10–11 –0.08 0.11 0.05
% able to contribute towards improvements at work
C. difficile 10–11 –0.2 –0.02 0.05
Fairness and effectiveness of incident reporting C. difficile 10–11 –0.13 0.07 0.01 Quality of job design (clear job content, feedback
and staff involvement)
intermediate outcomes, and also between staff experience and trust outcomes. Because of the changes in some outcomes (particularly mortality) in 2010 and 2011, we also give the year of measurement in the table because in this table only the interpretation of the values changes depending on which year is which. These findings reveal a relatively small number of significant effects, but some are not as expected.
In summary:
l When absenteeism is higher, this tends to lead to higher subsequent mortality, rather than vice versa.
l When turnover is lower, this is associated with greater mortality in the subsequent year.
l High infection rates of C. difficile are associated with higher subsequent staff absence than vice versa.
l When there are more opportunities for flexible working, mortality tends to be higher the following year
rather than vice versa.
l Worryingly, when there is lower patient satisfaction, this is associated with higher subsequent
discrimination (rather than vice versa).
l Higher patient satisfaction is associated with more flexible working subsequently and better subsequent
job design, rather than vice versa.
l When more staff recommend the trust and fewer experience harassment, bullying or abuse from
patients, this is associated with higher subsequent MRSA rates.
l A number of good job design factors are associated with lower subsequent C. difficile rates, rather
than vice versa.
As in Chapter 6, it is dangerous to read too much into these results, particularly for those that stand alone and/or are contrary to the direction expected from theory. However, it is clear that the picture of how staff experience and trust outcomes are linked is not straightforward and the relationship is certainly not a simple causal one. Staff experiences are likely to be affected by trust outcomes as well and it appears that this may not always be a positive thing, but it is impossible to say exactly how these effects occur.
Mediation
We tested for whether or not there were significant indirect (mediated) effects of the staff experience variables on trust outcomes via absenteeism or turnover. This analysis controlled for the usual
control variables for acute trusts, and used data from 2011/12 only.
Results suggested that there was not, on the whole, evidence of any mediated effects. Those that were significant are shown in Table 16. For patient mortality there were no significant indirect effects at all, as was the case for C. difficile rates. For patient satisfaction, there was a single indirect effect: that of the proportion of staff working extra hours, mediated by absenteeism. This is difficult to interpret because the indirect effect is positive, but small; the more staff working extra hours, the higher patient satisfaction is, but only very slightly. Given the singular nature of this effect, the fact it only just reaches statistical
significance and the number of effects tested, it is quite possibly a type I error and, therefore, we do not attach any particular significance to it.
However, for MRSA infection rates, there were a large number of significant indirect effects, again all via absenteeism. Most of the effects are actually for job design factors, suggesting that, when jobs are better designed and staff experiences are better, absence rates are likely to be lower and, as a result, MRSA rates are likely to be lower. However, we need to temper the interpretation of this with the results from the previous section, which cast some doubt over the direction of relationships between staff experience and infection rates. Therefore, we cannot assume there is indeed such a causal relationship and although a set of consistent and interesting results, it is too much of a step to say that this proves such a mediated link.
Summary of results
Overall, there is a real mix of results presented here. By far the most consistent and clear finding is the link between staff experiences and levels of patient satisfaction, replicating previous work examining these
constructs.106These reveal that there are clear associations, at least cross-sectionally, between many staff
experiences (across most domains) and patient satisfaction.
However, the longitudinal effects are much less clear. Cross-lagged correlations did reveal some patterns suggesting directional effects, for example that absenteeism in one year is more closely associated with mortality in the subsequent year than vice versa; however, others (particularly those involving infection rates) were much less convincing. There were some links between changes in staff experiences (particularly those relating to the quality of job design) and subsequent improvements in patient outcomes, but this was not consistently found across all predictors and all outcomes. This reveals the limitations of the analysis: looking at year-on-year changes may not be sensitive enough to the variables in question (particularly across whole trusts) to be able to detect time-lagged effects that could help provide more evidence for causality. Overall, it would be dangerous to conclude anything substantial from the cross-lagged correlations. The latent growth curve model results were not much clearer, as the stronger design (modelling change in staff experiences) revealed only a few statistically significant results, some of which could have been false positive findings. However, experiences linked to violence, harassment and actions dealing with it were linked (in the expected direction) with a number of different outcomes, suggesting that this may have not only impact on the staff immediate outcomes, but also directly on patients too.
TABLE 16 Significant indirect effects of staff survey variables on trust outcomes via absenteeism
Predictor Outcome
Indirect effect
estimate 95% CI
% staff working extra hours Patient satisfaction 0.04 0.00 to 0.09 % feeling valued by colleagues MRSA –0.01 –0.05 to 0.00 Quality of job design (clear job content, feedback and
staff involvement)
MRSA –0.79 –2.33 to –0.15
% working in a well-structured team environment MRSA –0.52 –1.67 to –0.03 % staff working extra hours MRSA –0.01 –0.03 to 0.00 % feeling there are good opportunities to develop potential
at work
MRSA –0.01 –0.03 to 0.00
Support from supervisors MRSA –0.55 –1.58 to –0.10 % suffering work related stress in previous 12 months MRSA 0.01 0.00 to 0.04 % experiencing physical violence from other staff in previous
12 months
MRSA 0.05 0.01 to 0.15
% reporting good communication between management and staff
MRSA –0.01 –0.02 to 0.00
% able to contribute towards improvements at work MRSA –0.01 –0.03 to 0.00 Job satisfaction MRSA –0.61 –1.73 to –0.13 Intention to leave job MRSA 0.27 0.01 to 0.90 Staff recommendation of the trust as a place to work or
receive treatment
MRSA –0.35 –1.00 to –0.07
Staff motivation at work MRSA –0.69 –2.00 to –0.13 Overall engagement MRSA –0.64 –1.79 to –0.15
In terms of the mediation, a striking finding was that, although may staff experiences were associated with absenteeism and patient satisfaction, there were no mediated effects here. That is, the reason for staff experiences affecting absenteeism appears completely separate from the reason they affect patient satisfaction. Given that both are important for trusts for different reasons, this points to an even greater importance of staff attitudes and experience.
Chapter 8 Examination of relationships
differing by groups
Chapter summary
This chapter gives the findings from the analysis relating to the third research question, which was